Provider Demographics
NPI:1346776390
Name:CLARK, ANGELA (APRN)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:CLARK
Suffix:
Gender:
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:427 US 31W BYP
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42101-1703
Mailing Address - Country:US
Mailing Address - Phone:270-467-1701
Mailing Address - Fax:270-467-1770
Practice Address - Street 1:427 US 31W BYP
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101-1703
Practice Address - Country:US
Practice Address - Phone:270-467-1701
Practice Address - Fax:270-467-1770
Is Sole Proprietor?:No
Enumeration Date:2017-05-11
Last Update Date:2025-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3011302363LP2300X, 363LF0000X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily